An Clinicopathological And Survival Analysis Of Non-Squamous Cervical Cancers At AHPGIC

Introduction

The global incidence of cervical cancer burden is disproportionally high in low and middle income countries, where 83% of all new cases and 855 of cervical cancer death occur [1]. India accounts for nearly one fourth of the worlds cervical cancer deaths, with 60,078 death and 96, 922 new cases in 2018 [2, 3]. Cancer cervix the most probe cause of maternal mortality in Indian women. Adenocarcinoma represent 20-25% of cervical cancers in the industrialized countries.

Most of this is due to relative decrease in incidence of squamous cell carcinoma. In contrast to squamous carcinoma smoking does not i9ncease the risk adenocarcinoma. squamous and non squamous differ in hpv status [4]. Hpv 18 accounts fo 50% of nonsquamous cell cancer (adenocarcinoma) of 15% of squamous cell carcinomas. Management of adenocarcinoma is same as squamous.

Whee as squamous disseminate via lymphatics and adenocarcinoma haematogenous route [5].

This is evident as as after lymphatic disseminiation adenocarcinoma has poor prognosis compared to squamous cell carcinoma.[6]

Other evidence in support of haematogenous spread [1]. the largest series of surgically teated cervical cancers demonstrated a significantly highe rate of ovaian metastasis with adenocarcinoma (5%vs .8%p<.01).

2. a study of 367 pts of adenocarcinoma from M.D ANDERSON hospital reported a higher rate of distant metastasis for stage II (46%VS13%) and stage III disease (38%vs21%) when compared squamous carcinoma.

Thee are are very few studies regading the prognostic factors ie clinical and pathological factors influencing the parametrium positivity and nodal status of non squamous carcinoma. that is the reason they ae ovetreated by multimodality i.e(radical sugery with adjuvant).

Studies done by M.d Anderson on 29 patients of adenosquamous and 97 pts of adenocarcinoma in stage 1b1., with radical hysterectomy. On follow up time to recurrence (7.9mths vs 19 monthsp-.01).

A STUDY OF 163 adenocarcinoma and adenosquamous carcinoma with stage 1A2 to IIB disease treated by radical hysterectomy with o without adjuvant radiation found no difference in ecurence ate or patterns of ecurences between the two groups, in both low risk, intermediate risk high isk group.[7]

One hundred patients met the inclusion criteria.

The median age was 35 years (range 22-65), and 51% (51/100) had pure high-grade neuroendocrine carcinoma.

No patient had a tumor > 4 cm or suspected parametrial or nodal disease before surgery. Ten patients (10%) had microscopic parametrial compromise in the final surgical specimens. Ninety-four (94%) patients underwent nodal assessment, and 19 (19%) had positive nodes. Ten patients underwent both sentinel lymph node biopsy and pelvic lymphadenectomy, and none had false-negative findings. Patients with parametrial compromise were more likely to have positive pelvic nodes (80% vs 12%, p<0.0001), and a positive vaginal margin (20% vs 1%, p=0.03). All patients with parametrial compromise had lymphovascular space invasion (100% vs 73%, p=0.10). of the 100 patients, 95 (95%) were recommended adjuvant therapy and 89 (89%) were known to have received it. adjuvant pelvic radiotherapy reduced the likelihood of local recurrence by 62%.[8] gloria salvo et al.

Descriptive Statistics

A total 22 cases of non squamous carcinoma were taken for statistical evaluation The median age incidence is 46 yrs. The youngest age is 28 yrs and maximum age 62 yrs. 9(40.9) were <46 yrs and noscaese more than 46 yrs 13(59.1). 4 cases i.e18.9% cases were multiparous and 4(18.2) cases were nulliparous. the spectrum of presentation varied from pmb 9(40.9) cases, watery discharge 9(22) noscases, aub were 4(18.2) and pcb 4(18.2) TABLE1. Of the total 22 cases all 22 (100)(%) underwent; laparotomy 20 (90.9) cases underwent type 2 radical hysterectomy,and 2 cases underwent type 3 radical hysterectomy. There were intraoperative surgical complications and 22(100) post operative complications. There wee 4(18.2) cases with a high residual urine and rest had minor bladdedysfunction 18 (81.8) table -2.

The high residual urine post op for the four cases wee200 ml, 90ml, 150ml, 150ml. After adjuvant treatment all four case required re-catherterisation.

There were 2(9.09%) were adenosquamous ,1(4.55%) case was basaloid carcinoma and rest 20 (91%)cases were adenocarcinoma

The median size of the lesion is 3 cm .7 (33.3%) cases wee lessthan 3 and 15 (66.7%) cases ae moe than 3 cm mmagins positive in 10 (45.4%) cases and negative in12 (54.6%) lvsi positive in 7 (31.8%) and 15 cases (667 %) negative nos of grade 1 10(45.4) and grrade 2 6(27.3%) and grade 3 6(27.3%)

Nodal status shows the pelvic node 8 (36.4%). Paaaortic2(9.1%)

The depth of invasion >5mm 25(31.8%) and <5mm 7(68.2%)

The parametrium was postive in 5 cases (22.7%) cases was negative in 17(77.3%) cases adnexa was not positive in any of cases

17 () were in stage 1. With no case in 1a, 6 cases in 1b1, 9 cases in 1b2 and 2 cases in 1b3. Thee were 5 cases in stage 3. None of the cases pesented in stage 2 and stage 4.

Survival Analysis

Figures

Results

On regression analysis with dependent variable as the pelvic node was analysed with age, depth of invasion and size of lesion and parametrium, none of factors were significantly influencing the nodal status.

Similarly the parametrium positivity taken as the dependent variable was analysed with age , size of lesion,depth of invasion. none of the factors could predict the parametrial involvement. overall 5-year survival probability for the patients is 0.770 i.e 55 months with 95% CI (0.570, 1.000). Here, the 5-year survival probability for the patients with parametrium positive status is 0.917i.e 48months 95% CI (0.773, 1.000). The log rank test for change in survival between two parametrium groups i.e., negative and positive patients gives chi-square value 3.59 (d.f.=1, p-value = 0.06), which indicates two groups do not differ in their survival.

Disease free survival of the parametrium –ve/ parametium +ve(60/24 mths). The log rank test for change in survival between two parametrium groups i.e., negative and positive patients gives chi-square value 2.8 (d.f.=1, p-value = 0.1), which indicates two groups do not differ in their disease free survival.

Conclusion

The parametrium and nodal positivity of non squamous cancers ae not dependent on each other. Thus we conclude fom overall survival of parametrium positive/parametrium negative (48mths/55mths) or the disease free survival of the two groups (24mths/60 mths) after radical hysterectomy with adjuvant ctrt was not statisticaly significant. Although the parametrium negative cases showed increase in overall survival of 55mths and disease free survival of 60 mths.

Thus we can subject the patients to either of a single modality of treatment i.e either a radical hysterectomy or ctrt.